Debbie Klee-Yokum shows some left over bottles of pain medication she used to use to manage her chronic pain at her home in Sunnyvale, Calif., on Friday, February 25, 2011. Debbie Klee-Yokum went through "step therapy" in order to get her chronic pain under control, and after dozens of prescription trials with little success of pain management she found success through meditation, relaxation and empowering her mind to control the pain.

Photo: Thomas Levinson, The Chronicle

Debbie Klee-Yokum shows some left over bottles of pain medication...

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Debbie Klee-Yokum went through "step therapy" in order to get her chronic pain under control, and after dozens of prescription trials with little success of pain management she found success through meditation, relaxation and empowering her mind to control the pain. Klee-Yokum is seen explaining the process she went through trying different prescriptions while at her home in Sunnyvale, Calif., on Friday, February 25, 2011.

The old adage "if at first you don't succeed, try, try again" doesn't sit well with pain patients who are often forced to try several different drugs before their health insurer covers the treatment recommended by their doctor.

A bill proposed by a Marin County lawmaker would limit that practice - known as "step therapy" or "fail first" - to two unsuccessful attempts. After the second failure, insurers would be required to pay for what the doctor prescribed.

"Step therapy is used for lots of things, but the point of focusing on chronic pain sufferers is that truly this is an area where a person's physician ought to be able to call the shots on how to relieve this patient of pain," said Assemblyman Jared Huffman, D-San Rafael, author of the bill, which was introduced earlier this month.

The bill has the support of many pain sufferers, such as Debbie Klee-Yokum of Sunnyvale. Klee-Yokum has been trying for 12 years to manage chronic pain that was triggered by surgery.

"I had to go through that game of trying drugs that either had no effect, or most of them just made me very sick," said Klee-Yokum, 55.

Fighting many battles

Klee-Yokum, who was diagnosed with a condition called complex regional pain syndrome, said her condition has gone into remission and she is now able to manage without medication. But she said she went through a lot to get to that point.

"You can feel like you're fighting the battle by yourself between the system, the doctor, insurance companies and the pharmaceutical companies," she said.

Health insurers say step therapy helps control costs by encouraging patients and doctors to try generic or cheaper medications rather than the newest, most expensive and heavily marketed drug. They say it also limits the possibility of patients becoming dependent on pain medications because it initially steers them toward drugs that are less addictive.

"Health plans want a prescription benefit that has constraints on the frequently abused pain medications that, regrettably, some physicians prescribe for patients who can become addicted to them," said Patrick Johnston, chief executive officer of the California Association of Health Plans.

Johnston said many options remain for patients under the current practice, including paying a higher co-payment for a more costly drug or appealing the insurer's decision. "Essentially we're talking about the potential of a delay from one medication to another medication, not a denial," he said.

Physicians who manage pain bristled at the notion of needing a gatekeeper to protect their patients from the drugs they believe are best.

Expensive drugs

Dr. Moshe Lewis, a pain specialist at California Pacific Medical Center in San Francisco, acknowledged the new pain medications are expensive and that some controls may be necessary to curb costs, but he said the pharmaceutical companies could help by lowering their prices after they recoup the money they spent on research and development.

"We do find some of the less-expensive medications that are generic don't work as well as some of the branded medications," he said, adding that some of the newer painkillers have fewer side effects as well as special formulations that help reduce the likelihood of abuse and addiction.

Dr. Melanie Henry, assistant professor of anesthesia and pain medicine at UCSF, said step therapy can interfere with the relationship she has with her patients. "You're denying the patient the pain relief they could have when this could have been a better drug for them," she said.

Second attempt

This is Huffman's second attempt at this legislation. Last year, he introduced a bill that would have banned step therapy. The bill passed the Assembly, but failed in the Senate Appropriations Committee after an analysis found it would increase health costs, particularly to public health programs such as Medi-Cal.

Huffman hopes his newer, scaled-down version will succeed.

"There are chronic pain sufferers all over California who are living with this condition every day," he said. "Their awful burden is just compounded when their insurance company makes them try multiple medications and fail before they finally get the medication they need."